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Full text of "United States Navy Medical News Letter Vol. 25, No. 1, 7 January 1955"

NavMed 369 




Editor - Captain L. B. Marshall, MC, USN (RET) 



Vol. 25 Friday, 7 January 1955 No. 1 



TABLE OF CONTENTS 

Residency Training Policy . 2 

Histological Study of Effusions 3 

Treatment of Angina Pectoris with Cinchona Alkaloids 6 

Tuberculosis Risk in Children of Tuberculous Parents. . . 8 

Unobtrusiveness in Treating Obesity 9 

Pheochromocytoma 12 

Cardiopericardiopexy . . . 13 

Acute Pancreatitis 15 

Primary Cancer of the Breast 17 

Automobile Collision Injuries 19 

Treatment of Nonpenetrating Abdominal Injury 20 

Early Treatment of the Neurogenic Bladder . . 22 

Intermediate Coronary Syndrome 24 

Retirements 25 

Training Course in Special Weapons, Isotopes, and Military Medicine. 26 

Medical Military Training Program 27 

Change of Address 27 

Reserve Selection Board for Promotion to Lieutenant Commander 28 

Request for Obsolete Issues of Hospital Corps Handbook 28 

Medical Correspondence Course - Combat and Field Medicine 29 

From the Note Book 29 

Dental Technician In-Service Training Program (BuMed Notice 1500). .31 

Diagnostic Titles, Instructions Relating to {BuMed Notice 6310) 31 

PREVENTIVE MEDICINE SECTION 

Reference Publications 32 

Reference Bibliography „ 34 

Acoustic Trauma 35 

Nonoccupational Disability • 36 

Environmental Medicine 37 

Care in Using Insecticides 38 



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Medical News Letter, Vol. 25, No. 1 



Policy 

The U.S. Navy Medical News Letter is basically an official Medical 
Department publication inviting the attention of officers of the Medical De- 
partment of the Regular Navy and Naval Reserve to timely up-to-date items 
of official and professional interest relative to medicine, dentistry, and 
allied sciences. The amount of information used is only that necessary to 
inform adequately officers of the Medical Department of the existence and 
source of such information. The items used are neither intended to be nor 
susceptible to use by any officer as a substitute for any item or article in 
its original form. All readers of the News Letter are urged to obtain the 
original of those items of particular interest to the individual. 

Notice 

Due to critical shortage of medical officers, the Chief, Bureau of 
Medicine and Surgery, has recommended, and the Chief of Naval Personnel 
has concurred, that Reserve medical officers now on active duty who desire 
to submit requests for extension of their active duty for a period of three 
months or more will be given favorable consideration. 

$ $ $ $ $ $ 

Residency Training Policy for 
Reserve Medical Officers on Active Duty 

The response by Reserve medical officers to the Residency Training 
Program for Reserve officers, as provided in BuMed Instruction 1520.7, 
has been most gratifying. There are several vacancies remaining in the 
following residency programs : Pathology, Orthopedic Surgery, Obstetrics 
and Gynecology, Pediatrics, and Urology. A very limited number of billets 
are still available in Otolaryngology, Anesthesiology, and Ophthalmology. 
While applications for training in the above specialties should be for one 
year at a time, it is expected that in most instances officers who partici- 
pate in this program will be permitted to complete their required training 
without interruption. Every effort will be made to accomplish this insofar 
as service needs will permit. 

Reserve medical officers on active or inactive duty, who have com- 
pleted their obligated active duty imposed by the Universal Military Train- 
ing and Service Act, as amended, are eligible for participation in this 
program. Reserve officers on inactive duty must request return to active 
duty in order to be assigned to such training. 



Medical News Letter, Vol. 25, No. 1 



3 



Eligible and interested medical officers should make applications 
to the Bureau of Medicine and Surgery, via the chain of command. Letters 
of application should contain an agreement to volunteer for the period of 
residency training requested and to remain on active duty in the Navy for 
a period of one year following completion of training, for each year of 
training received. 

From time to time the list of medical specialties in which shortages 
exist will be published in the Medical News Letter, (ProfDiv, BuMed) 

Histological Study of Effusions 



This is a detailed morphological study of the cellular forms, identi- 
fied in effusions from the pleural, peritoneal, and pericardial cavities. 
The investigation was undertaken in order to study: (1) the cellular 
changes not associated with malignant neoplasm, and in particular , those 
that might be misinterpreted as evidence of cancer; and (2) the changes 
observed in the presence of malignant tumors. 

The results of the investigation are presented in two parts. The 
first is concerned with features of the cells in effusions that are not 
associated with malignant tumor, while the second deals with the cellular 
forms observed in the presence of malignant tumors or their metastases. 

Part I 

In the first study 396 pleural, peritoneal, or pericardial fluids of 
known etiology not associated with malignant neoplasm, were reviewed 
critically in order to examine cells and' cell groupings that might be mis- 
interpreted as evidence of malignant tumor. In the presence of long- 
standing effusion, the proliferation of mesothelial cells was responsible 
for unusual cell groupings and alterations in isolated cells known to be 
of mesothelial origin. The masses of mesothelial cells were regarded 
as being aggregates, rosettes, or acinar-like structures. Of these, 
a gg re gates were the most common, being observed in 148, or 37% of the 
fluids. The rosettes and acinar-like masses were less common, being 
observed respectively in only 36, or 9%, and 23, or 6% of the specimens. 
In general, aggregates were more common with cirrhosis and congestive 
failure and were less numerous in effusions of tuberculous origin. Acinar- 
like structures similarly were more common with congestive failure and 
Laennec's cirrhosis as were rosettes, the latter not being observed in 75 
specimens of tuberculous effusions. This would seem to indicate that meso- 
thelial proliferation was less apparent in the presence of effusion with tuber- 
culosis. 

Neither aggregates nor rosettes of mesothelial cells offered a seri- 
ous problem in differentiation from malignant neoplasm. The component 



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Medical News Letter, Vol. 25, No. 1 



cells were usually recognizable as mesothelial elements and. were not 
misleading. The acinar-like groupings were most disturbing. 

The isolated cellular constituents were regarded less often as 
being misleading to the critical microscopist. Several forms deserve 
special comment. Vacuolization of the mesothelial cells was common, 
being noted in 152, or 38%. In many cells the large vacuole displaced 
the nucleus to an eccentric position in the cell and the resulting form 
was not unlike that of the so-called "signet-ring" cell in adenocarcinoma. 
Special stains offered little help in such elements, because the inclusions 
were not infrequently positive or doubtful with the mucicarmine stain, 
representing glycoprotein material. In general, such forms should not 
be confused with those seen in adenocarcinoma. 

Giant cells occurred in 105, or 26% of the specimens. Because 
these were usually regarded as being of mesothelial origin, their dis- 
tinction from cancer cells offered no serious problem. An awareness of 
such cells is important in examining fluid specimens. 

Isolated cells in mitosis were observed in 33, or 8% of the fluids. 
The observer who has examined fluid specimens will not find these cells 
misleading. In general, a normal mitotic figure in an isolated cell in 
itself is not evidence of a malignant neoplasm. This is particularly true 
when the cell is regarded as being of mesothelial origin; however, when 
the cell type is regarded as being of lymphocytic origin and in addition, 
other cells are present, the problem is more difficult. 

The most difficult problem in examining the isolated cells was en- 
countered in the presence of tuberculosis. While only rarely was adeno- 
carcinoma even remotely considered, the distinction between tuberculosis 
and leukemia or lymphosarcoma on an objective basis was more difficult 
in isolated cases. This was a problem in those cases of tuberculosis in 
which there were numerous cells of lymphocytic origin, many of which 
were transition forms to medrum-sized lymphocytes. The presence of 
mitoses in such cases added to the difficulty. In the interpretation of a 
specimen, it was not possible to exclude mature lymphocytic lymphosar- 
coma or leukemia, although distinction from lymphoblastic lymphosar- 
coma was possible. Seven, or 15% of the cases of tuberculosis presented 
such a problem. Obviously, the clinical data in such cases was of consid- 
erable value in arriving at a correct interpretation. In some instances 
a" superior preparation might have permitted a more accurate differential 
diagnosis because the degenerative changes in the lymphocytes made exam- 
ination difficult. 

Part II 

This is a detailed morphological study of the cellular elements in 
pleural, peritoneal, and pericardial effusions associated with malignant 
tumors or their metastases. This study is based on the examination of 
619 effusions from 339 patients with malignant neoplasms. These 



Medical News Letter, Vol. 25, No. 1 



5 



specimens constituted all of the fluids received from patients in whom 
there was definite clinical or pathological evidence of malignant neoplasm 
during the interval of the study. The recognition of malignant tumor cells 
in effusions is of importance in establishing a diagnosis in otherwise ob- 
scure cases. In some instances, these cells not only aid in establishing 
a diagnosis of malignant tumor but also in determining the site of origin 
of the tumor. 

In this study, the origin of malignant tumor cells was often suggest- 
ed by their characteristic appearance and arrangement in adenocarcinoma 
of the lung, papillary adenocarcinoma of the ovary, and in the lymphomas. 
In 31 of the 49 specimens containing malignant tumor cells derived from 
adenocarcinoma of the lung, numerous large isolated cells were either 
the only arrangement of the malignant tumor elements or the predominant 
one. Cellular membranes were prominent and the cytoplasm was abundant, 
acidophilic, and finely to coarsely vacuolated. 

The nuclear forms were large, pleomorphic, and often multiple. 
Mac ronucleoli and mitotic figures were frequent. In 18 of the effusions 
there were aggregates of the cancer cells and acinar-like forms. 

In 26 of the fluids examined from patients with carcinoma of the 
ovary, there was a similar cellular arrangement. This consisted of 
numerous cancer cells occasionally interspersed with erythrocytes. Other 
cellular elements were rare. The tumor cells were large and arranged 
as single cells, acinar-like forms, or irregular aggregates. The cyto- 
plasm was abundant and vacuolated; large "signet-ring" forms were com- 
mon. The nuclei were pleomorphic and often contained macronucleoli. 
Occasional papillary forms and calcific masses were noted. 

Among the specimens obtained from patients with lymphomas, two 
cellular arrangements were noted. The one occurred in effusions asso- 
ciated with either lymphosarcoma or lymphatic leukemia and consisted 
of numerous small, medium-sized or transition forms of lymphocytes. 
Other cellular elements were rare. This cellular picture was similar 
to that seen occasionally with tuberculous effusions. Mesothelial cells 
were usually present in the effusions associated with tuberculosis and 
were of aid in distinguishing the two. In patients with myeloid leukemia, 
the effusions showed numerous myelocytes, more immature forms of the 
granulocytic series, and neutrophils. In some cases large numbers of 
megakaryocytes were present. 

Tumor implants need not be present on the serosal surfaces in 
all cases of effusions associated with malignant neoplasms. The effusion 
may be secondary to mechanical obstruction of the veins, or lymphatics, 
or to a secondary inflammatory process. 

Malignant tumor cells were identified in 418, or 67.5% of the 619 
fluid specimens examined, and in 252, or 74,3% of the 339 cases. Cancer 
cells were present in effusions from 96% of the patients with carcinoma 



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Medical News Letter, Vol. 25, No. 1 



of the ovary, 94% of those with diffuse carcinomatosis, and in 78.5% to 
72.7% of those with carcinoma of the breast, digestive system, lung, and 
uterus. Lymphomas showed the presence of diagnostic cells less fre- 
quently than carcinomas. The presence of isolated large cancer cells 
was considered the most common arrangement of the exfoliated elements 
in adenocarcinoma of the lung. In papillary carcinomas of the ovary, the 
usual pattern was one of numerous malignant tumor cells arranged in 
acini and irregular clumps, with marked vacuolization of the cytoplasm. 
In many cases of myeloid leukemia and lymphosarcoma, the cellular pat- 
terns were distinctive. 

It was not possible to depend entirely on clumping or acinar.-like 
formations of malignant tumor cells. In adenocarcinoma of the lung, 
occasional undifferentiated carcinoma of the stomach, lymphosarcoma, 
and leukemia, isolated neoplastic elements were common, and some- 
times the only forms present. However, it was considered hazardous 
to make a diagnosis of malignant tumor cells on the basis of scattered 
atypical cells or isolated rare abnormal forms. (Cancer, Nov., 1954; 
S.A. Luse, M. D. and J. W. Reagan, M. D., West ern Reserve University, 
Cleveland, O. ) 

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Treatment of Angina Pectoris with 
Cinchona Alkaloids 



Previous studies have demonstrated the value of quinidine sulfate 
in the treatment of some patients with angina pectoris. However, most 
general practitioners, and in fact, many cardiologists hesitate to use 
quinidine in angina because of the complications which occasionally fol- 
low its use in the treatment of cardiac arrhythmias. Furthermore, many 
physicians hesitate to use quinidine in angina pectoris because its mode 
of action in this condition is not clear. It seemed worthwhile, therefore, 
to study the activity of drugs related to quinidine, in an attempt to find 
a substance equally effective but possibly less toxic, and also to throw 
some light on the mechanism of action in the treatment of angina pec- 
toris. 

The comparative value of 12 pharmaceutical preparations was 
investigated in patients with angina pectoris. Five of these 12 were 
cinchona alkaloids {the sulfate salts of quinidine, quinine, cinchonine, 
cinchonidine, and cinchamidine) ; these were studied to determine whether 
drugs which were similar to quinidine in chemical structure but different 
in cardiodynamic and cardiotoxic effects were of therapeutic value in 
angina. Procaine amide (Pronestyl) was included because, like quinidine, 
it is of value in eliminating ectopic ventricular beats. Three synthetic 



1 



Medical News Letter, Vol. 25, No. 1 



7 



antimalarial preparations (chloroquine, pentaquine, and chlorguanide) 
were chosen to see whether the therapeutic action in angina might be 
related to the mechanism responsible for antimalarial activity. Nitro- 
glycerin was used to determine which patients were likely to be benefited 
by vasodilator drugs, and also to compare the effectiveness of the cinchona 
alkaloids with that of nitroglycerin which is the most effective of the drugs 
for angina. Pentaerythritol tetranitrate (Peritrate) was included to com- 
pare the frequency and degree of response of the cinchona alkaloids with 
that of a preparation currently advocated for the treatment of angina pec- 
toris. Finally, placebos were used for control studies and to equalize 
the beneficial psychologic effects of treatment. 

Evaluation of the efficacy of treatment in angina pectoris is diffi- 
cult. The methods of evaluation included: (1) a comparison of the clinical 
response with measurements of the exercise tolerance under standard 
cold conditions, and studies of the effect of medication on the electrocar- 
diographic changes induced by exercise; (2) comparison of the value of the 
cinchona alkaloids with the ineffective placebos, the very effective nitro- 
glycerin and the slightly effective pentaerythritol tetranitrate, and (3) 
analysis of the results in two separate groups of subjects, those likely to 
respond to vasodilator therapy and those not likely to respond to such 
therapy. 

Four of the cinchona alkaloids (quinidine, quinine, cinchonidine, and 
cinchamidine) proved to be highly effective in some, but not all, patients 
with angina. The patients most likely to respond to these cinchona alka- 
loids were those who responded well to nitroglycerin. No toxic and few 
untoward effects were observed. 

Quinidine and quinine are among the most effective of the drugs 
now available for the treatment of angina pectoris. Quinine is the drug 
of choice because of low toxicity, effectiveness, and low cost to the patient. 
Quinine possesses little of the potential cardiotoxic effects of quinidine. 
The latter drug is equally available but somewhat higher in cost. Quinidine 
is possibly somewhat more effective in angina than is quinine. 

The effectiveness of the cinchona alkaloids in angina pectoris is 
due, at least in part, to a vasodilator action. The quinoline ring is 
probably the portion of the molecule primarily responsible for the thera- 
peutic effect. (Circulation, Dec., 1954; J. E. F, Riseman, M.D., 
L. A. Steinberg, M. D. , and G. E. Altman, M. D. , Beth Israel Hospital, 
and Harvard Medical School, Boston, Mass. ) 

****** 

The printing of this publication has been approved by the Director 
of the Bureau of the Budget, June 23, 1952. 



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8 



Medical News Letter, Vol. 25, No. 1 



Tuberculosis Risk in Children 
of Tuberculous Parents 

This article calls attention to the interesting paradox that, the 
closer the elimination of tuberculosis as a major public health problem 
becomes, the more important becomes the understanding of its epidem- 
iology. As the "irreducible minimum" of morbidity is approached, as 
it becomes more and more difficult to find the fewer cases in the com- 
munity, it also becomes more important to concentrate control efforts 
on those segments of the population which are most apt to provide a 
fruitful yield of new and previously undiscovered cases of the disease. 
The description and delineation of these crucial population segments 
depend on the epidemiologic study of factors which govern the occurrence ■ 
and distribution of tuberculosis in that population. 

As a group, children of tuberculous parents run an unusually great 
risk of developing tuberculosis. Most observers agree that this is due 
in large part to the highly intimate contact between the host and the sus- 
ceptible individual. Nevertheless, this is obviously not the whole ex- 
planation, because other groups of people in the same tuberculous house- 
holds, with similar opportunities for intimate contact with, but unrelated 
or more distantly related to the tuberculous host, have lower attack and 
death rates than close relatives. The difference is presumably attribu- 
table to the operation of a hereditary constitutional factor which makes 
close relatives of tuberculous persons more likely to develop tuberculosis. 

The children of tuberculous parents were selected for special in- 
vestigation because they are known to be particularly liable to develop 
tuberculosis, because they are a homogeneous group genetically, are 
easily identified, and are more readily kept under observation than most 
other members of tuberculous households. 

The tuberculosis attack rate was 3.3 per 1000 person-years among 
children of tuberculous parents with sputum positive for acid-fast bacilli, 
compared with a rate of 1.8 for children of a tuberculous parent in whom 
no bacilli were demonstrated. 

In the former group the highest rates were observed in those less 
than 5 years and in those 15 to 24 years of age. In the latter group, 
attack rates were extremely low in persons less than 15 years of age, 
but then rose and reached a peak at 25 to 34 years. 

The ultimate goal of epidemiology is to provide the factual know- 
ledge of disease necessary to bring about its control. If sufficient time, 
funds, and personnel were available, it might be justifiable to use broad, 
general epidemiologic factors as guides to a control program in tubercu- 
losis. However, with the perennial reduction in Federal funds for tuber- 
culosis control in recent years, and with the increasing cost of finding 
a case by general survey procedures, it is becoming more and more 



Medical News Letter, Vol. 25, No. 1 



9 



essential to concentrate control efforts on the most vulnerable segments 
of the population. The finer, more specific epidemiologic factors must 
be sought as guides in planning tuberculosis control programs. The fore- 
going data may suggest lines of approach in planning such programs. 

Children of parents with "open" tuberculosis should be observed 
closely, particularly during the first year of life and during the 15 to 24- 
year age period. In infancy the male child requires closer observation 
because of apparent greater susceptibility to tuberculosis than the female. 
During adolescence and early adulthood the female child appears more 
vulnerable to attack and should be watched carefully, although the male 
should not be ignored. Periodic examination of children should not cease 
because contact may have been broken with the tuberculous parent through 
moving out of the household. It appears that a sufficiently large number 
of new cases develop after removal to justify going beyond the confines 
of the household and continuing to observe removed contacts, particularly 
if the individuals are more than 25 years of age. 

If complete observation of all children of tuberculous parents is 
impossible, it appears safe to ignore those exposed for the first time 
between the ages of 1 and 14. After these children reacn 15 years of age, 
periodic examination is indicated. (Am. Rev. Tuberc., Dec., 1954; 
L. D. Zeidberg, A. Dillon, and R. S. Gass, Tennessee Dept. of Public 
Health, Franklin, Term, ) 

Unobtrusiveness in Treating Obesity 



Every physician realizes that obesity cannot be treated successfully 
by merely prescribing diets and drugs. Weight control obviously depends 
less on the therapy itself than on the degree to which the patient follows 
it. Failure of therapy can nearly always be traced to an inherent psycho- 
logic inadequacy of the patient. Therefore, it is the physician's respon- 
sibility to devise a regimen that will provide each patient with a maximum 
of protection against his own shortcomings. 

For an initial study, 27 patients were chosen whose histories had 
demonstrated clearly that they would be least likely to respond to weight 
control measures. Each had failed to respond to all previous therapy. 
Many of them had failed so frequently that their obesity had begun to appear 
a chronic and incurable condition. Their ages varied from 17 to 61 years, 
and their overweight varied between a marginal excess and gross obesity. 
Several patients whose weight excess was still quite minor were included 
in the study in the hope of checking a demonstrated trend toward progres- 
sively serious obesity. In approximately one-third of the patients studied, 
obesity was complicated by diabetes or hypertension or both. 



10 



Medical News Letter, Vol. 25, No. 1 



Prior to therapy, the author spoke frankly to each patient, warning 
him of the dangers of his condition and pointing out the psychologic over- 
tones of his inability to lose weight. Each patient was asked to provide 
a description of his normal diet and the eating habits dictated by his 
usual social activities. Using these facts as a basis, the author outlined 
the framework of a diet of about 1200 to 1500 calories which approximated 
as closely as possible the individual eating pattern described. Patients 
were not told that they must not eat cake or ice cream, nor were they for- 
bidden soft drinks or beer. Realizing that these foods are the staples of 
social eating, moderation rather than abstinence was stressed. 

Because of the familiarity of these patients with conventional regimens, 
the lack of taboos usually engendered a feeling that the treatment was "too 
easy. " This, however, provided an excellent opportunity for bringing 
home the importance of unobtrusivenes s , the essential feature of the regi- 
men. It was easy to explain that although normal people may be pleased 
to see the successful results of diet, they dislike intensely having the diet 
itself paraded before them. Each patient was shown how the flaunting of 
his treatment in public intensified his craving for forbidden foods and at 
the same time drove his friends, bored by the constant talk of diet, to vent 
their annoyance by tempting him to abandon his overadvertised regimen 
and by ridiculing him when he did so. Avoidance of this trap, it was ex- 
plained, dictated the only specific taboo of the regimen: don't talk about 
the treatment. 

Rather than to rely exclusively on the ease of the regimen to insure 
patient adherence, anorexigenic drugs were utilized as well. A daily dose 
of 15 mg. of d-amphetamine sulfate was prescribed in the sustained- release 
dosage form. It was possible to include this drug in the regimen without 
violating the essential secrecy of the treatment. The patients were in- 
structed to take one capsule each morning before breakfast. 

Special attention was given to the psychologic outlook of each patient, 
as well as to any clinical abnormalities that coexisted with his obesity. 
The duration of observation ranged from 4 to 39 weeks, the average time 
being 17 weeks. 

The average weekly weight loss for this group of patients was 1.1 lb., 
which was 0.2 lb. less than reported by Gelvin and McGavack using com- 
parable doses of amphetamines and a diet of 1060 calories. 

The patients reported that they experienced comparatively little 
difficulty in keeping their treatment secret until weight losses became 
apparent. In anticipation of this problem, it had been suggested that the 
patient acknowledge the fact that he was under treatment when it became 
obvious. They were cautioned, however, to be casual about it, to avoid 
details, and above all, to refrain from volunteering information. This 
approach was quite satisfactory in heading off discussion. Few patients 
were pressed for details, apparently confirming the premise that normal 
people are rarely interested in the details of obesity. 



Medical News Letter, Vol. 25, No. 1 



11 



The results obtained with one patient, although statistically poor, 
were particularly gratifying because they were obtained during pregnancy. 
This patient's previous pregnancy had been complicated by an excessive 
gain in weight and by severe nausea and vomiting. Nausea, which was 
present when the patient started treatment, was promptly relieved, and 
rather than gaining weight, she actually lost 10 pounds. 

This regimen was not intended to supplant the current methods of 
therapy. It was designed, rather, to establish basic guide lines thatmight 
help to clarify and improve the approach to the psychologic aspects of treat- 
ing obese patients. The significa/ic e of the results lies, not in the tabu- 
lated weight losses, but rather in the fact that all of the responses recorded 
were obtained with patients who had consistently failed with previous ther- 
apy. 

Although the study is clearly too limited to be regarded as conclu- 
sive, it does suggest that an unobtrusive regimen may succeed where 
essentially similar therapy, lacking only the factor of unobtrusiveness , 
has consistently failed. 

At the same time, the success obtained from the purely psychologic 
advantages of this approach tends to confirm the importance of the psychic 
factor in obesity therapy and to lay added emphasis on the need for the phys- 
ician to provide a regimen that is as sound psychologically as it is physio-' 
logically. In this connection, the exceptionally good mental attitude of 
these patients while undergoing treatment deserves mention. Although the 
"easy" regimen undoubtedly contributed to this, experience with the mood 
ameliorative properties of amphetamines, confirming the observations 
of Williams, leads one to credit this type of drug with an appreciable « 
psychologic "assist. " It is interesting to note how closely the actions of 
the drug parallel the essential features of the regimen. It improves mood, 
curtails appetite, and in the sustained-release dosage form, even succeeds 
in being unobtrusive. 

Throughout the study, there were almost no side effects to therapy 
with d-amphetamine sulfate. Normotensive patients showed no apprecia- 
ble alteration in blood pressure. Concurrent with their loss of weight, 
eight patients, whose obesity was complicated by hypertension, demon- 
strated a reduction in blood pressure. This is not meant to imply that 
d-amphetamine sulfate is treatment for high blood pressure per se, but 
to emphasize that this drug can be included quite safely i,n a weight reduc- 
tion regimen for people having hypertensive vascular disease. (GP, Dec, 
1954; J. C. Cohen, M. D. , Philadelphia) 



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12 



Medical News Letter, Vol. 25, No. 1 



Pheochromocytoma 

One of the curable forms of hypertensive cardiovascular disease 
is that caused by pheochromocytoma, although the actual frequency of 
these tumors is low. In a series of over 2400 hypertensive patients 
treated surgically, only 15 were found to have a pheochromocytoma, an 
incidence of about 0.5%. The appalling fact, however, revealed by a 
review of the literature, is that pheochromocytoma is diagnosed only at 
autopsy in about 70% of reported cases. Because surgical removal is 
almost always followed by cure of the disease, it is important that the 
index of suspicion be high, that diagnostic points be kept clearly in mind, 
and that the management of the patient before, during, and after operation 
be thoroughly understood and properly carried out. 

Pheochromocytomas develop from chromaffin tissue and are thus 
located wherever it is found. Ninety percent are found in the adrenal 
medulla, but they may also occur in the lumbar or thoracic paravertebral 
spaces, in and about the great vessels of the abdomen, in the organ of 
Zuckerkandl at the bifurcation of the aorta, in the celiac ganglion, and 
even within the cranial cavity. The tumors are bilateral in 10%, and are 
malignant in about 10% of the cases. 

Pheochromocytomas secrete epinephrine and norepinephrine in vary- 
ing amounts and proportions. This fact has important implications which 
concern the operative management of these patients, and is discussed in 
detail. 

Although the hypertension of pheochromocytoma is commonly par- 
oxysmal, it may be nonparoxysmal and the disease be almost indistinguish- 
able from essential hypertension. Once the lesion is suspected, however, 
various measures may be employed to verify the diagnosis because no 
single test is infallible. These measures include the eliciting of certain 
characteristic signs and symptoms, roentgenologic examinations, the use 
of various test drugs, and finally operative exploration. 

Smithwick and his collaborators in a comprehensive study of the 
problem have laid particular emphasis on certain signs and symptoms 
that occur frequently in patients with pheochromocytoma but are not usu- 
ally found in patients with essential hypertension. Most of these appear 
to be related to the presence of epinephrine or norepinephrine in the cir- 
culating blood. They are excessive sweating, peripheral vasomotor phe- 
nomena (vasoconstriction), elevated body temperature (IF. or more), 
normal cold-pressor blood pressure response, fasting blood sugar level 
of 120 mg. per 100 cc. or more, basal metabolic rate of 20% or more, 
postural tachycardia and postural hypotension, glycosuria, and paroxys- 
mal attacks of hypertension. This data is readily obtained by any physician 
and requires no special facilities. When any of these symptoms are present 



Medical News Letter, Vol. 25, No. 1 



13 



the physician should be on the alert for pheochromoc ytoma. Intravenous 
pyelography, laminography, and perirenal air injection may be helpful in 
visualizing the location of a pheochromocytoma. 

In the authors' experience with operations on hypertensive patients 
having either essential hypertension or pheochromocytoma, serious acci- 
dents occur more frequently from failure to cope with episodes of hypo- 
tension than from hypertension. For this reason, preparation of patients 
for operation with blocking agents and the use of these agents to reduce 
pressure during operation, is avoided. In the event that other measures 
to reduce dangerous blood pressure levels are unsuccessful, and it be- 
comes necessary to employ a blocking agent, regitine is preferred because 
of the short duration of its action. 

The authors agree with Apgar and Papper that the selection of anes- 
thesia is perhaps less important than understanding of the physiologic 
principles underlying management. The circulation must be supported. 
Adequate ventilation must be maintained. Endotracheal intubation is oblig- 
atory. Spinal anesthesia and cyclopropane are best avoided, the former 
because of the danger of circulatory collapse, and the latter because it 
sensitizes the heart to epinephrine and norepinephrine. Rapid induction 
with a mixture of thiopental sodium and a muscle relaxant may precipitate 
a dangerous vascular collapse. Muscle relaxing agents have not been em- 
ployed for this group of patients except in 1 or 2 cases in which mytolon 
chloride was administered to facilitate intubation when splanchnicectomy 
was the proposed operation, and the pheochromocytoma not previously 
diagnosed was discovered in the course of the operation. No untoward 
effects were noted following the use of this drug. Also, no serious effects 
were noted which could be ascribed to the sympathomimetic effects of ether. 
(Anesthesiology, Nov., 1954; J. E. Thompson, M. D. and J. G. Arrowood, 
M. D. , Massachusetts Memorial Hospitals, and the Boston University 
School of Medicine, Boston, Mass.) (See U.S. Navy Medical News Letter, 
Vol. 20, No. 5, and Vol. 22, No. 5. ) 

!{C S$C 3{C s£c 3{c !$£ 

Cardiopericardiopexy 

The various operative procedures advocated to reestablish adequate 
myocardial circulation, and the many approaches may be grouped into four 
surgical tenets: (1) the grafting of a vascular tissue to the myocardium 
(omentum, lung, skeletal muscle, mediastinal fat and spleen); (2) arteria- 
lization of the coronary veins, as channels to increase oxygenation, by 
means of a vascular anastomosis; (3) implantation of the internal mammary 
artery into the ventricular myocardium, and (4) creation of a benign, per- 
manent and chronic granuloma between the visceral and parietal layers of 



14 



Medical News Letter, Vol. 25, No. 1 



the pericardium. Cardiopericardiopexy falls into the last-mentioned cate- 
gory, and this article is confined to a description of the procedure and a 
brief recital of its results. 

What is cardiopericardiopexy, and how simple or complex is its 
execution? Of all the surgical procedures advocated for the treatment of 
diseases that have their basis in myocardial ischemia, cardiopericardio- 
pexy is unquestionably the most modest in concept and the simplest to 
perform. The operation can be completed in 30 minutes or less. It is 
not necessary to open the pleural cavity. No intricate, time-consuming 
anastomosis, always involving the possibility of thrombosis, is required. 
It is a one-stage procedure. It does not demand special skills or talents 
other than those possessed by any well-trained and experienced general 
surgeon who is familiar with the anatomic and physiologic nature of the 
heart and the mediastinal structures. Incisions are not extensive and 
are not carried through heavy muscles rich with blood. 

The operation of cardiopericardiopexy, as performed, may be 
illustrated best as taking place in three steps": Step 1 includes positioning 
of the patient, incision of the skin, and exposure and excision of the costal 
cartilage. Step 2 exposes the anterior mediastinum, including the peri- 
cardium. In Seep 3 the pericardium is opened, the sac is explored, talcum 
powder is introduced and the surgical wound is closed. 

What are the postoperative problems? Shock, arising from pro- 
longed exposure and excessive handling of vital tissues and organs, is 
never experienced. Although the problems encountered after the operation 
are unusual and peculiar to this procedure, they are almost always limit- 
ed in number, extent, and gravity, and they seldom terminate in death. 
These special problems may be grouped into those due to operative trauma 
those due to foreign body reaction, and those due to the diseased condition 
of the heart. Postoperative pain is, on the whole, a minor complication; 
it is neither severe nor prolonged, persisting only for a few days, and may 
be controlled by the administration of sedatives and analgesics. The foreign 
body reaction, which is invoked by the talc introduced into the pericardial 
sac, reflects itself in a rise of temperature and involves the lungs, pleura, 
heart, pericardium, and mediastinum. None of these complications is of 
sufficient gravity to endanger life. 

By far the most important of the complications that follow cardio- 
pericardiopexy are those which arise because of the diseased state of the 
heart. Although extrasystoles may develop frequently during the operation, 
they are encountered only occasionally thereafter. Undoubtedly, the most 
serious problem is coronary occlusion. 

What are the benefits derived from cardiopericardiopexy? Clinical 
improvement is statistically significant. In a 15-year study of patients who 
had undergone cardiopericardiopexy, 90% were improved more than 50%, 
and 40% were improved more than 75%, as shown by decrease in anginal 



Medical News Letter, Vol. 25, No. 1 



15 



pain, increase in exercise tolerance, and improvement in ability to attend 
to their daily needs and return to a former, or some other, gainful occu- 
pation. In addition to this physical improvement, the patients who died 
after undergoing surgical treatment lived for an average of 5 years, which 
gives them an average life span of 9-1/2 years from the onset of the first 
symptom. This compares favorably with the average life span of 4-1/2 
years (from the onset of the first symptom) of the patient treated medical- 
ly for coronary disease. Statistically, cardiopericardiopexy contributed 
5 years to the life of the average patient who underwent the operation. 
(J. Internat. Coll. Surgeons, Nov., 1954; S. A. Thompson, M. D. and 
L. A. Akopiantz, M. D. , New York City) 

$ jje gjc # $ $ 

Acute Pancreatitis 



Etiologic factors causing acute pancreatitis may be summarized as 
follows: (1) trauma which in itself may bring about the liberation of some 
toxic body formed by the escape of products, the result of proteolytic 
action in the presence of free blood due to blood vessel injury; (2) diseases 
of the blood vessels, such as arteriosclerosis, endarteritis, and ather- 
oma leading to thrombosis; (3) conditions causing a. reflux of bile or duo- 
denal contents through the pancreatic ducts into the pancreas, such as 
(a) gallstones, (b) stone in the common duct, (c) stone in the ampulla of 
Vater, (d) tumor of the ampulla of Vater, (e) tumor of the common duct, 
(f) cicatrization. of the ampulla of Vater, and (g) intestinal stasis; (4) 
by the lymphatic route, especially by means of the lymphatics of the gall- 
bladder and its neighboring structures; (5) by way of the blood stream, 
i. e., occurring in the course of acute infectious diseases; and (6) from 
unknown causes bringing about proteolytic pancreatic activity. 

Probably due to the rarity of this condition as compared with the 
frequent occurrence of so many of the acute abdominal diseases, the 
physician or surgeon of even a few years ago was prone to overlook a 
case of acute pancreatitis. The average physician and surgeon has devel- 
oped a more or less acute consciousness of pancreatitis and are not as 
baffled as before. From a clinical standpoint, physicians observe (1) the 
transient or usually milder form, and (2) the culminating or catastrophic 
form which runs a stormy and frequently fatal clinical course. 

In the ultra-severe or catastrophic type the most striking symptoms 
are pain and shock. The former is usually agonizing and constant, with 
but little interval between the paroxysms, and is seldom controlled by 
morphine. The pain generally originates in the upper abdomen, most 
often in the epigastrium and right abdominal quadrant, radiating to the 
left or the right of the median line and then gradually over the entire ab- 
domen, and is preceded as a rule by a general abdominal soreness. 



16 



Medical News Letter, Vol. 25, No. 1 



Radiation to the back occasionally occurs. In this type of case, intense 
pain has been a constant factor. Profound shock and collapse, accom- 
panied by an increased rapid pulse rate with a distinct fall in blood pres- 
sure, soon ensues and the patient becomes markedly prostrate. Early 
circulatory collapse is pronounced and the presence of cyanosis and 
dyspnea with a fairly good pulse and without demonstrable cardiac or 
pulmonary cause is typical of this form of acute pancreatitis. As a rule 
nausea and vomiting is persistent and gastric lavage or medication rarely 
give relief. 

A mass may or may not be present; as a rule it is absent. Disten- 
tion is usually greater than muscular rigidity although the latter is always 
present to a certain extent, more pronounced in the epigastrium and the 
upper quadrants and to a lesser degree in the lower quadrants. 

Leukocytosis is variable but in most cases is fairly elevated. Gly- 
cosuria is a most inconstant and fairly rare occurrence, but when found, 
is of extreme diagnostic importance. The presence of hyperglycemia is 
of great significance and should be investigated in all cases of suspected 
pancreatitis. 

The subacute cases embrace those which present a longer duration 
and which rarely present an acute course. The patient is often seen in an 
intoxicated condition due to peritonitis or multiple abscess formation. The 
presence of an epigastric mass is often noted in this type. 

The rise in serum amylase is almost always due to complete or par- 
tial obstruction of the main pancreatic duct. In acute pancreatitis, the 
onset of symptoms is accompanied almost simultaneously with a rise in 
serum amylase. Usually there is an abrupt rise, most often reaching 
its peak within the first 48 hours, but sometimes within 4 to 6 hours. 

The duration of serum amylase elevation seems to have some prog- 
nostic value. Transient elevation, which returns to normal or sub-normal 
values within 2 to 3 days after the peak has been reached, is thought to be 
associated with pancreatic edema. In other cases the elevation may per- 
sist with a gradual drop in serum amylase over a period of many days. 
In these cases extensive necrosis of the pancreas may have occurred. 
However, a precipitous drop is not always a sign of improvement but may 
mean that extensive necrotic distribution of the pancreas has occurred 
within a short period of time. 

When an amylase level of 150 units or more is associated with acute 
abdominal pain, the presence of acute pancreatitis should be strongly sus- 
pected. It should be emphasized, however, that the rise in serum amylase 
is not confined to acute pancreatitis. An increase usually accompanies 
inflammatory conditions of the parotid and salivary glands, and less often 
follows the use of codeine and other opiates. Very occasionally, an in- 
crease may be noted in cases of renal insufficiency, carcinoma of the 
pancreas, and perforated peptic ulcer. 



Medical News Letter, Vol. 25, No. 1 



17 



There is no question but that amylase determinations have been of 
great advantage in diagnosis, and that the use of antibiotics (especially 
penicillin, sulfanilamide, sulfadiazine, and streptomycin) has altered 
the line of treatment. It must be borne in mind, however, that cases 
will be seen which may demand surgical procedures. Unless there has 
been a definite diagnosis of acute pancreatitis, it is better to explore 
than to take the chance of the condition being of another nature. Each 
case must be considered as a problem and treatment must be carried 
out in accordance with the surgeon's best judgment. In every case pre- 
senting pain in the upper quadrants, estimation of the blood sugar and 
amylase should be obtained. This may be of the greatest diagnostic help. 
(Am. J. Surg., Dec, 1954; J. L Donhauser, M. D. , Albany Medical 
College, Albany, N. Y. ) 

****** 

P rimary Cancer of the Breast 

In 100 consecutive women with primary cancer of the breast, some 
will be apparently operable when first seen, some questionably operable, 
and some frankly inoperable. The proportions naturally vary in different 
localities, but in most reported series, about 60% of cases fall into the 
first or apparently operable group, and about 40% into the other two groups. 

In the operable group, radical surgery results in some 80% five- 
year survivals when the axillary lymph nodes are negative for tumor, 
and in about 30% such survivals when the lymph nodes are positive. There- 
fore, in this favorable group, there are some 30 women whose tumors are 
arrested for five years; of these, about 19 had negative lymph nodes (and 
would presumably have survived by simple operation alone), and about 
11 had positive lymph nodes (and, therefore, represent an apparent salvage 
by the radical procedure). 

Radical surgery is contraindicated in most of the questionably opera- 
ble, and in all of the frankly inoperable cases. It may hasten the spread 
of fresh cancer emboli throughout the chest wall and body, and will actually 
shorten survival time in some patients. 

There are, therefore, about 11 out of the 100 cases in which the 
radical operation is of significant value in terms of survival. This group 
will contain some patients with radiosensitive growths and some with radio- 
resistant ones. The authors believe that adequate postoperative radiotherapy 
will do more for the axillary lymph nodes in those members of this group 
with radiosensitive lesions than will radical dissection of the axilla. It will 
not spread neoplastic cells; it should destroy or suppress tumor. Converse- 
ly radical dissection will do more for those members of the group with 
radioresistant lesions. 



18 



Medical News Letter, Vol. 25, No. 1 



The question, therefore, is, what is the proportion of radiosensitive 
and radioresistant tumors in this hypothetical group of 1 1 patients? If it 
is equally divided, either method should give equal end results in terms 
of over-all salvage. If radiosensitive lesions predominate, simple opera- 
tion plus postoperative irradiation will have more to offer than radical 
surgery. 

Because the radiosensitivity of lesions is not determinable prior to 
treatment, and because surgical removal is a more certain method of 
eradicating a localized (i. e. , removable) breast cancer than is radiother- 
apy, it is advisable that surgery be used to remove the primary lesion 
in all apparently operable cases; it permits identification of the tumor, 
serving as an excisional biopsy with minimum chance of disseminating 
disease. 

The 5 and 10-year survival rates in properly selected "operable" 
cases are essentially the same whether the treatment be radical mastectom 
or simple mastectomy and postoperative radiotherapy. The radical pro- 
cedure is still preferable to the simple operation in a special group of 
patients with operable lesions (the very obese woman, the apical tuber- 
culotic, and the unstable individual who will probably fail to complete her 
postoperative therapy course). 

Patients with presumed internal mammary lymph node involvement 
(especially those with central or inner quadrant tumors) probably should 
have additional radiotherapy to this area. 

The place of simple mastectomy and vigorous postoperative radio- 
therapy in the treatment of primary operable cancer of the breast appears 
to be well established. Where skilled radiotherapeutic service is avail- 
able, the author believes it it the method of choice in most cases seen in 
practice today. It still remains to be confirmed that late recurrences in 
the chest wall and axillary areas are no higher with this combined proce- 
dure than they are with the radical operation. If this does not eventuate, 
the procedure will require re-evaluation. 

The long term control of cancer of the breast, in terms of absolute 
ten-year survival rates, is as good with the simple procedure plus adequate 
radiotherapy as it is with the radical procedure; there is some evidence to 
suggest that, under average conditions of practice, it is actually better. 

The physical comfort of the average woman treated by simple opera- 
tion and postoperative radiotherapy appears to be greater than after the 
radical procedure. However, either method still fails to cure a majority 
of women with breast cancer today. (Roentgenology, Dec. , 1954; 
L. H. Garland, M. D. , Stanford University Medical School, San Francisco 
Calif. ) 



Medical News Letter, Vol. 25, No. 1 



19 



Auto mobile Collision Injuries 

An important step in the campaign for greater safety in highway 
travel is the study of the causes of injury in automobile accidents. The 
accumulation of data regarding the nature, location, and source of these 
injuries will provide a basis for the development of adequate protective 
measures; related to the details of the various accidents, this information 
will also aid in the identification of hazards in the design and structure of 
automobiles. The successful completion of this study requires the pooling 
of data from many observers. 

An account of the findings in a series of patients who were injured 
in automobile collisions is presented in this report. A total of 3196 in- 
juries, as classified in this study, occurred in a group of 1475 patients. 
There were no fatalities. 

Multiple injuries were found in approximately three-fourths of the 
drivers, two-thirds of the passengers in the front seat, and three-fifths 
of the passengers in the rear seat. 

Almost three-fifths of the total number of injuries were abrasions 
and contusions. Approximately one-eighth of the injuries were those of 
whiplash effect on the neck, while approximately one-fifth of the total num- 
ber were strains or sprains in other locations. Approximately one in three 
of the injuries involved the head and neck, one in ten the chest, one in five 
the arms and shoulders, and one in three the back or legs and pelvis. 

The injuries of the drivers were principally those of the head and 
neck, arms and shoulders, or back, while those affecting the passengers, 
whether occupants of the front or rear seats, were predominantly injuries 
of the head and neck, arms and shoulders, or legs and pelvis. 

The principal cause of injury in this series of patients appeared to 
be uncontrolled motion of the occupant in relation to that of the automobile. 
This factor has been the subject of recent comment by Schaefer and by 
Campbell. In abrupt deceleration, as in a head-on collision, the occupant 
continues to move forward at approximately the velocity of the automobile 
in the instant preceding the accident, until he is stopped by impact against 
the steering wheel, wind-shield, or dashboard. The rate of deceleration 
of the occupant under such circumstances may be many times greater than 
that of the acceleration of gravity. In abrupt acceleration, as in a collision 
from the rear, the automobile is thrust forward beneath the occupant. A 
whiplash injury results when the head and neck are snapped backward, or 
when such hyperextension is overcorrected. These mechanisms may be 
combined in the multiple collisions which often occur in heavy traffic. 

Various measures have been suggested to provide protection against 
these effects of acceleration. The seat belt is a well-known example. 
Securely anchored to the frame of the automobile, such a device can hold 
the occupant firmly and squarely in the seat, literally forcing him to wear 



20 



Medical News Letter, Vol. 25, No, 1 



the automobile as a suit of armor. The use of the seat belt in aircraft 
and in racing cars has already established its value, but while its instal- 
lation involves little cost or effort, it has yet to find wide acceptance. 

The adoption of other suggested measures requires appreciable 
change in the automobile. A representative listing includes: elimination 
of all sharp edges and projections; adoption of push-button controls and 
recessed fittings; generous use of padding throughout the automobile; 
use of plastic or of "popout" windshields; installation of a flexible joint 
in the steering column which will yield under pressure, or the adoption 
of aircraft-type levers in place of the steering wheel; installation of non- 
rigid dashboards; elevation of the backs of the seats, to support the head 
and neck; use of locking or anchoring devices on all seats; installation of 
periscope rearview mirrors; use of body construction material which will 
deform or absorb the force of impact; installation of "oleo" shock-absorbing 
bumpers. Woodward has already emphasized many of these recommenda- 
tions. 

A change in the design or structure of automobiles is a matter of 
considerable expense. Such steps are not likely to be taken by manufac- 
turers until the needs for specific protection are established by adequate 
study. The accumulation of data from many observers, preferably in 
suitably standardized form, is, therefore, of great importance. The find- 
ings in the present analysis provide a cross- section review of nonfatal 
collision injuries in an area where high-speed driving is probably excep- 
tional. There is need for additional studies from other areas, where road 
conditions or driving practices differ, before valid conclusions can be 
drawn. (Surgery, Dec., 1954; R. G. Livingston, M. D. , Cambridge, Mass. ) 

$$$$$$ 

Treatment of Nonpenetrating A bdominal; Injury 

No lesion requires closer observation or more careful judgment in 
the selection of treatment than that following nonpenetrating abdominal 
trauma. Such trauma may cause any and all types of injury to both solid 
and hollow viscera. With the increasing number of automobile, industrial, 
and other accidents, the problem is rapidly becoming one of major import- 
ance. In spite of increasing frequency of this type of injury, each case is 
completely different from others, and the diagnosis and treatment should 
be based on the clinical manifestations. 

Therefore, no hard and fast rules can be applied in managing these 
highly individualized problems. The difficulties are only slightly simpli- 
fied by the fact that even in cases of nonpenetrating abdominal trauma, 
there are certain criteria that demand immediate surgical exploration. 
The roentgenographic demonstration of free air in the abdomen is perhaps 
the clearest indication for immediate laparotomy. A rapidly falling red 



Medical News Letter, Vol. 25, No. 1 



21 



cell count is equally important. Rapidly increasing tenderness accompanied 
by increasing leukocytosis must not be ignored. 

It must be stated at the onset that, if there is a reasonable doubt as 
to the integrity of the bowel, and if the patient is a fair operative risk, an 
exploratory laparotomy should be performed. To operate early will not 
increase the risk materially, and it often will simplify the treatment of 
a lesion that may become very complex, after the passage of 6 to 8 hours, 
owing to edema and spreading peritonitis. 

The first step is a careful history and physical examination. To sus- 
pect the existence of these intra-abdominal lesions is a long step toward 
their recognition. These lesions may follow the most trivial of injuries, 
as brought out in a case report. They may follow mild juggling action on 
the back seat of an automobile, or other minor trauma. Physical exam- 
ination is essential, because it may at once reveal an abdominal lesion 
and it establishes a baseline for future examinations. 

The second step is a complete roentgenologic examination. This must 
include the pelvis, the spinal column, and the thoracic cage. A roentgeno- 
gram of the abdomen should be made to determine whether or not free air 
is present beneath the diaphragm. The patient seldom is so severely in- 
jured that a scout film of the abdomen cannot be made in order to detect 
the presence of free air. Fractures of the ribs or vertebrae often lead 
to abdominal distention and at first give the impression that an intra- 
abdominal lesion exists. Fractures of the pelvis will put the physician 
on guard for rupture of the bladder or urethra. 

The third step is immediate catheterization of the patient, if he is 
unable to void. Gross blood in the urine usually means injury of the ure- 
thra, bladder, or kidneys, and must be further investigated. 

The fourth step is a complete blood count. This may be of relatively 
little value soon after an injury but establishes a valuable baseline for 
future comparisons. 

Fifth, because most of these patients are in a moderate degree of 
shock, whole blood typed should be crossmatched so as to be immediately 
available during the operation which is likely to follow. 

Sixth, in cases in which immediate diagnosis is not possible a Wan- 
gensteen suction tube must be introduced to prevent further abdominal 
distention which will tend to further obscure an already confusing clinical 
picture. 

Seventh, it is vitally important that repeated, careful examinations 
should be made at short intervals by the same surgeon. 

When to operate on a patient who has received a blow on the abdomen, 
who does not have free air in the abdomen, or a ruptured bladder, but who 
does have abdominal pain with moderate rigidity is the $64 question. It is 
believed that a delay of 2 or 3 hours is not harmful if the surgeon is in 
doubt, as is usually the case. Morphine is definitely contraindicated 
during this period. 



22 



Medical News Letter, Vol. 25, No. 1 



At the end of this time, the same surgeon, or surgeons, should re- 
examine the patient, and laboratory tests should be repeated. Increasing 
abdominal pain and rigidity demand an exploratory operation. Changes 
in both the red cell and white cell counts may be of great significance, 
as may changes in the abdominal findings. This is the reason it is so 
important that the same surgeon see the patient frequently until the diag- 
nosis is established. Only he can properly evaluate any change in the 
clinical picture, and his opinion is worth much more than that of a con- 
sultant who is called in as a last desperate measure to help throw light 
on the very confusing picture which is usually present 6 to 12 hours after 
injury 

When the abdominal injury is the only one, it is probably safer to 
operate when in doubt. If it is one of several serious injuries, especially 
of the chest or skull, then the indications for operation must be clear be- 
fore a laparotomy is performed. In cases of multiple injuries, it is per- 
haps safe to delay operation and to observe the patient closely for periods 
up to 6 to 8 hours. Then, if the abdominal symptoms and findings progress, 
the surgeon may be forced into a high-risk laparotomy to save the patient's 
life. In any case, the surgeon or surgeons in attendance should, at the end 
of 6 or 8 hours, if they have carefully and repeatedly examined the patient 
and correlated the clinical findings, be able to decide whether or not to 
operate. 

When the decision has been made to perform an exploratory laparo- 
tomy, it is only common sense and of utmost importance that the state of 
shock be corrected as well as possible and that adequate blood for trans- 
fusion be available in the operating room. Occasionally, the rapidly bleed- 
ing patient who is in deep shock may require simultaneous transfusions in 
two or three, or even four extremities before his condition can be brought 
to a point where he will withstand operation. 

It must be remembered that nonpenetrating and penetrating trauma 
can cause exactly the same lesions. Each injury should be treated accord- 
ing to well-established surgical principles. {Postgrad. Med. , Dec. , 1954; 
C.M. Burgess, Straub Clinic, Honolulu, T. H. ) 

* # * 3fc $ & 

Early Treatment of the Neurogenic Bladder 

In World War I, 60% of the spinal cord injury cases who survived 
their initial trauma, died of urinary tract infection. With a better under- 
standing of bladder physiology and the introduction of chemotherapeutic 
agents and antibiotics, this mortality rate was reduced to 15% in World 
War II. The figures for the Korean War are not yet available. With 
proper management, the morbidity and mortality from urinary tract 



Medical News Letter, Vol.. 25, No. 1 



23 



infection in paraplegia can still be much further reduced, and these un- 
fortunate individuals can be restored to a satisfactory and productive life. 

Nesbit and Lapides classify the neurogenic bladder into five groups 
depending upon the location of the lesion. This classification is neurologi- 
cally sound, but in gunshot wounds of the spinal cord, the lesions are fre- 
quently incomplete and produce mixed and bizarre types of neurogenic 
disease of the bladder. 

The uninhibited neurogenic bladder . In this type there is a loss of 
cerebral inhibition over reflex bladder contractions. The reflex neurogenic 
bladder. This type results from complete transection of the spinal cord 
or from gross lesions which are comparable to transverse myelitis. The 
autonomous neuroge nic bladder. This occurs when both limbs of the pri- 
mary reflex arc are destroyed by lesions of the sacral cord, conus, or 
cauda equina, of both motor and sensory roots in the sacral plexus. The 
sensory paralytic bladder . This occurs when the sensory limb of the 
segmental or supra segmental reflex arc is interrupted. The motor para- 
lytic bladder . This is due to interruption of the motor pathway in the seg- 
mental or supra s egmental arc. Acute anterior poliomyelitis is the primary 
cause of this type of bladder. 

Following injury, an urethral catheter should be inserted under 
sterile precautions before the bladder overdistends . A small Foley cath- 
eter (16F. - 18F. ) should be used. The use of a large catheter may in- 
duce trophic ulceration of the urethral mucosa from pressure with second- 
ary periurethral abscess. Intermittent catheterization should never be 
used where these facilities are available. Tidal drainage or intermittent 
manual irrigation are equally effective. Subey's "G" solution or 1/8% 
phosphoric acid solution are excellent irrigating media. 

Fluid intake should be measured and forced to 3000 cc. daily. Tes- 
tosterone seems to have a beneficial effect in conserving nitrogen; under 
this therapy, trophic ulcers heal more rapidly, the patients look better 
and experience a feeling of well being. If phosphates are present in the 
urine, intramuscular hyaluronidase will decrease the turbidity. All 
patients with indwelling catheters show some pyuria. If this is excessive, 
appropriate antibiotics should be administered following urine culture and 
sensitivity tests. In the absence of any other findings to explain febrile 
episodes, they must be attributed to pyelonephritis and treated accordingly. 
The usual localizing signs of this condition are absent because of the level 
of anesthesia. 

Intolerance of the urethral catheter, manifested by severe urethritis, 
periurethral abscess, or epididymitis, is indication for suprapubic cysto- 
stomy. The catheter should be changed only when incrustations appear 
in the lumen. As recovery from the spinal shock phase occurs, the pa- 
tient is aware of vague discomfort during bladder irrigations. He can 
now be given a test of reflex voiding by removal of the catheter or clamping 



24 



Medical News Letter, Vol. 25, No, 1 



the suprapubic tube. If unsuccessful after a few hours, drainage is again 
instituted. The authors found that cystometric studies were not too helpful 
as a gauge of returning bladder function. 

Because the care of the paraplegic is a joint professional responsi- 
bility, weekly rounds by a paraplegic board, consisting of a neuro- surgeon, 
urologist, and psychiatrist, with such other medical officers as may be 
involved in the care of the patient, are useful in reviewing the progress 
of the patient and planning future therapy. {Mil. Surgeon, Dec, 1954; 
Col. J. W. Schwartz, MC USA, Walter Reed Army Medical Center, 
Washington, D. C. ) 

The Intermediate Coronary Syndrome 

The intermediate coronary syndrome may be defined as a complica- 
tion of coronary heart disease in the nature of an acute attack which is 
distinguishable from the anginal syndrome by an evaluation of the pain 
and distinguishable from myocardial infarction by the absence of the 
characteristic symptomatology of infarction. This syndrome is limited 
to cases in which the predisposing factor is coronary atherosclerotic 
heart disease, and the precipitating factors may be obvious or obscure. 
The characteristic symptomatology includes pain, nonspecific electro- 
cardiographic changes, minimal or equivocal systemic effects, and 
little, if any, evidence of circulatory failure. 

Differentiation from the anginal syndrome is usually easy because 
symptoms either develop spontaneously, or there is a dramatic decrease 
in exercise tolerance from one day to the next. Differentiation from 
myocardial infarction is based mainly on the absence of electrocardio- 
graphic alterations, considered to be pathognomonic, or nearly so, of 
myocardial infarction, and the absence of systemic effects or a friction 
rub attributable to myocardial necrosis. 

The clinical course is usually short and ends with recovery or the 
development of further injury, usually infarction. The treatment should 
include the relief of any obvious precipitating factor, the possible use of 
anticoagulant drugs, and a period of observation beyond which complica- 
tions are unlikely. 

The advantages in differentiating this middle category of cases of 
coronary heart disease include: (1) the possibility of defining more sharply 
the anginal syndrome and myocardial infarction, and (2) the stimulation of 
interest in the early recognition and treatment of complications of coronary 
heart disease which are not likely to end in infarction. 

The term intermediate coronary syndrome meets the clinical require- 
ment in designating these cases. (U. S. Naval School of Aviation Medicine, 
NAS, Pensacola, Fla. ) NM 001 059.06. 09, 15 September 1954. 



Medical News Letter, Vol. 25, No. 1 



25 



Retirem ents 

Captain Clarence L. Blew, MC USN, was transferred to inactive 
duty on the Temporary Disability Retired List of the Navy effective 
December 1, 1954. He was retired with the rank of Rear Admiral, MC 
USN. 

Admiral Blew entered the Navy as a Lieutenant, junior grade, 
Medical Corps, in June 1929. He served, during World War I, with the 
Marines in France and has received the Purple Heart Medal for wounds 
sustained in action. 

Admiral Blew received his Bachelor of Science degree from Kansas 
University in 1921, and the degree of Doctor of Medicine from the same 
school in 1925. He interned at the Montreal General Hospital, Montreal, 
Canada, and received post-graduate instruction in ophthalmology at 
Washington University School of Medicine in St. Louis. 

A member of the American Medical Association, Admiral Blew 
served, during his active Naval service, at the Naval Hospitals at Great 
Lakes, Illinois; Puget Sound, Washington; Bainbridge, Maryland; and 
Philadelphia, Pennsylvania. He was Executive Officer of the Naval Hos- 
pitals at Pensacola, Florida; Memphis, Tennessee; and Annapolis, Mary- 
land; as well as Executive Officer of the Hospital Corps School, Bainbridge, 
Maryland. 

Captain Thomas W. McDaniel, Jr. , MC USN, was placed on the 
Retired List of the Navy on December 1, 1954. 

Captain McDaniel received his Bachelor of Arts degree from 
Ouachita Baptist College in 1925; his Master of Science degree from 
Little Rock College, Little Rock, Ark., and the degree of Doctor of Med- 
icine from the University of Arkansas School of Medicine in 1931. He 
attended a postgraduate course in Internal Medicine at the University of 
Pennsylvania School of Medicine, 1938-1939. 

Captain McDaniel served in the USS Gold Star; at the Naval Station, 
Guam; with Mobile Base Hospital #1 during World War II; at the Marine 
Corps Recruit Depot, Parris Island, S. C. ; as Officer in Charge of the 
Navy Unit at the Public Health Service Hospital, Fort Worth, Tex., and 
in the Naval Hospitals at Puget Sound, Wash. ; Mare Island, Calif. ; Phila- 
delphia, Pa. ; Washington, D. C. ; Bethesda, Md. ; and San Diego, Calif. 

Captain McDaniel is a member of the American Medical Association 
and the American Psychiatric Association; and a Diplomate of the American 
Board of Psychiatry and Neurology. His address in retirement is 313 River- 
crest Drive, Fort Worth, Texas. 

LCDR Carol M. Pfeiffer, Nurse Corps, USN, was transferred to inactive 
duty on the Temporary Disability Retired List of the Navy on Dec. , 1, 1954. 



26 



Medical News Letter, Vol. 25, No. 1 



A native of Hartford, New Jersey, LCDR Pfeiffer graduated from 
the Pennsylvania Hospital School of Nursing, Philadelphia, in 1931. She 
entered the Navy in 1934, and received the degree of Bachelor of Science 
in Nursing Education from Catholic University, Washington, D. C. , in 1952. 
She attended a short course in "Nursing Team Organization and Functioning" 
at Teachers College, Columbia University, New York City, in 1953. 

During her active Naval service, LCDR Pfeiffer served with Naval 
Base Hospital #2 and Mobile Base Hospital #6; at the Naval Dispensary, 
Navy Department; at the Naval Training Center, Gulfport, Miss. ; and in 
the Naval Hospitals at League Island and Philadelphia, Pa. ; Annapolis 
and Bethesda, Md. ; Great Lakes, 111. ; Seattle, Wash. ; and St. Albans, N. Y. ) 
{TIO, BuMed) 

t * * t ♦ * 

Training Course in Special Weapons, Isotopes, 
and Military Medicine for Reserve 
Medical and Dental Officers 



The fourth annual course, "Special Weapons, Isotopes, and Military 
Medicine, " will be sponsored by the Inspector, Naval Medical Activities, 
Pacific Coast, and presented by the Commandant, Twelfth Naval District, 
during the period 28 February - 4 March 1955, at the U.S. Naval Station, 
Treasure Island, San Francisco, Calif. 

This course has been arranged to provide Reserve Medical Depart- 
ment officers of the Armed Forces the latest information to be employed 
in the many and varied aspects of special weapons, isotopes, and military 
medicine and dentistry. Each subject will be presented by a speaker of 
prominence in the specialty concerned. 

Eligible Reserve officers will receive retirement point credits, on 
the basis of one (1) point for each day of attendance. Reserve Medical 
Department officers desiring point credits for attendance must obtain 
authority and appropriate orders to assure accreditation. Officers who 
hold appropriate duty orders, and a limited number of officers in the 
Active Status Pool, may be issued orders to active duty for training with 
pay. A tentative program and applications for active duty training and/or 
authorized orders will be mailed prior to 1 January 1955. 

Naval Reserve Medical Department officers who have performed 
fourteen (14) days active duty for training, with or without pay; retired 
officers; or officers on the Inactive Status List are invited to attend this 
course without orders and will not receive retirement point accreditation. 

Although this course is intended primarily for Naval Reserve Med- 
ical Department officers of the Pacific Coast, active duty personnel are 
invited to attend, as well as other components of the Armed Forces, the 
Public Health Service, and Civil Defense personnel. (DMO, 12th N, D. ) 



Medical News Letter, Vol. 25, No. 1 



27 



Medical Military Training Program 

The Naval Medical School, National Naval Medical Center, Bethesda, 
Maryland, will conduct the fifth two-weeks course in Medical Military 
Training for the primary benefit of reserve officers of the Medical Depart- 
ments of the Armed Forces on inactive duty, 7-19 March 1955. 

The first week of this course is devoted primarily to the medical 
aspects of special weapons and radioactive isotopes, with emphasis on 
the basic concepts of atomic medicine. The second week is a medico- 
military symposium aimed at informing reserve personnel concerning 
the Medical Reserve programs and the activities of the Medical Depart- 
ments in general, presenting recent advances in military medicine, in- 
cluding aviation, submarine, and field medicine. A panel discussion of 
the Army, Navy, and Air Force Reserve Medical Programs will be in- 
cluded. The subjects will be presented by speakers of outstanding prom- 
inence in their specialties. Hence, a most interesting and informative 
program is assured. 

It is considered undesirable for officers who have attended this 
course within the past year to attend this year, as the change in subject 
matter from one year to the next is not sufficient to warrant repeating 
the course at such short intervals. 

Naval Reserve Medical, -Dental, Medical Service, Nurse, and Hos- 
pital Corps officers on inactive duty in the First, Third, Fourth, Fifth, 
Sixth, Eighth, and Ninth Naval Districts, and PRNC, who desire to attend 
this course in a pay or non-pay status, should submit their request to 
their commandant for appropriate active duty for training orders at the 
earliest practicable date. Officers of these corps attached to pay units 
of the Naval Air Reserve should submit their request to the Chief, Naval 
Air Reserve Training. A quota providing for attendance at this course 
in a pay status has been assigned each of these commands. 

Meals will be available in the Commissioned Officers' Mess (Open) 
and the general mess. Accommodations in the Bachelor Officers' Quarters 
will be very limited and will be allocated on a first come, first served 
basis . 

Reserve Medical Department officers on inactive duty who have not 
attended this course during the past year are urged to avail themselves 
of this excellent training. (ResDiv, BuMed) 

$ s[t jfc * * $ 

Please forward requests for change of address for the News Letter 
to: Commanding Officer, U.S. Naval Medical School, National Naval 
Medical Center, Bethesda 14, Md. , giving full name, rank, corps, and 
old and new addresses. 

$ $ $ $ $ sje 



28 



Medical News Letter, Vol. 25, No. 1 



Reserve Selection Board for Promotion 
to Lieutenant Commander 



A selection board is tentatively scheduled to convene at the Navy 
Department, Washington, D. C. on or about 15 February 1955, to recom- 
mend Naval Reserve Medical, Medical Service, and Nurse Corps officers 
for promotion to lieutenant commander. Officers eligible for considera- 
tion by this board are those lieutenants whose date of rank is prior to 
1 July 1951, and who: (1) are on inactive duty in an active status and who 
earned a minimum of 12 retirement points during fiscal year 1954; or 
(2) are on active duty in the TAR program; or {3) report for active duty 
on or after 1 July 1954. 

Officers who are within the above promotion zones should take in- 
dividual action to insure that fitness reports for training duty, annual 
fitness reports, and annual qualification questionnaires covering periods 
ending prior to the convening dates are submitted to the Bureau of Naval 
Personnel in time to be included in the officers' records when presented 
to the selection board. Special fitness reports are not required; however, 
any officer eligible for consideration for promotion by a selection board 
shall have the right to forward through official channels a written com- 
munication inviting attention to any matter of record concerning himself 
which he deems important to his consideration. The communication may 
not criticize or reflect upon the character, conduct, or motive of any 
other officer. 

Naval Reserve medical officers on inactive duty from different 
geographical sections of the country will constitute the majority member- 
ship of this board. (ResDiv, BuMed) 

****** 

Request for Obsolete Issues of 
Hospital Corps Handbook 

The Commanding Officer of the Hospital Corps School, USNH, 
Great Lakes, Illinois, proposes toestablisha historical exhibit of prior 
issues of the Hospital Corps Handbook and related material that might 
be of historical interest to the students. Hospital Corps Handbooks 
published prior to 1939 are desired. 

Owners of such old books or other historical matter who desire 
to donate such material are requested to communicate with the command- 
ing officer, U.S. Naval Hospital Corps School, USNH, Great Lakes, 111. 



Medical News Letter, Vol. 25, No. 1 



29 



Medical Correspondence Course - 
Combat and Field Medicine 

The Medical Department correspondence course, "Combat and 
Field Medicine Practice, " NavPers 10706 {1954 Revision, from thesis 
to objective type questions), is now available for distribution to eligible 
applicants. 

The purpose of this course is to train and instruct Medical Depart- 
ment personnel in the problems of combat and field medicine. The text 
material provides information regarding the medical aspects of amphib- 
ious warfare, care of battle casualties, field sanitation, insect control, 
water supply, chemical warfare agents--their characteristics and actions-- 
and the correct treatment for various chemical warfare casualties along 
with classification of casualties. 

This course consists of eight (8) objective type assignments and is 
evaluated at twenty-four (24) Naval Reserve promotion and non- disability 
retirement points. Personnel currently enrolled in the old thesis type 
course will receive promotion and retirement points authorized at the 
time of enrollment. {NavMedSch, NNMC , Bethesda) 

sjs % sjc $ Of 9js 

From the Note Book 

1. Rear Admiral D. W. Ryan, DC USN, Assistant Chief for Dentistry 
and Chief of the Dental Division, Bureau of Medicine and Surgery, will 
leave Washington on January 16, 1955, to visit Naval dental facilities 
at Coco Solo, C. Z. ; Trinidad, B. W. I. ; San Juan, P. R. ; Guantanamo 
Bay, Cuba; and Key West, Florida. Rear Admiral Ryan will return to 
Washington, D. C. on February 7, 1955. While in San Juan, P. R. , he 
will present a lecture at the annual meeting of the College of Dental 
Surgeons of Puerto Rico. (TIO, BuMed) 

2. BuPers Instruction 1210. 4A of Nov., 15, 1954, has revised and con- 
solidated the definition of certain billet and officer designator codes. 
One of those affected is that to be used for designating dental students 
under instruction as prospective Dental Corps officers. Formerly 
known as Ensign 1135, the new designator is called the Ensign 1995 . 

3. Naval Reserve Dental Company #8-5 of Dallas, Tex., held a training 
period meeting and dinner at Baylor University Hospital on Dec., 7, 1954. 
Dr. J. J. Addison presented a motion picture in sound and color called, 
"Hazards of Dental Radiography. " A special program was also held on 
Dec, 8, 1954, at which Lt. C. Ochsenbein, DC USNR, of Austin, presented 
a thesis and clinic on "A Practical Peridontal Application for the General 



30 



Medical News Letter, Vol. 25, No. 1 



Practitioner with Emphasis on Restorative Dentistry following Treatment. " 
CDR P. J. Murphey, DC USNR, is the commanding officer of Naval Reserve 
Dental Company #8-5. (TIO, BuMed) 

4. The contributions of a young Naval laboratory technician loaned to the 
Osaka National University, Osaka, Japan, for the purpose of indoctrin- 
ating technicians in the Medical School's Central Clinical Laboratory, has 
attracted much attention among medical circles in Japan. William L. Jones, 
Hospital Corpsman First Class, of the U.S. Navy Fleet Epidemic Disease 
Control Unit No. Two, taught the medical technicians methods he had learned 
as a Naval Laboratory Technician. These methods, as Dr. Miyaji, Path- 
ologist at Osaka National University, explained, "were found more accurate 
and simple than had been carried out in this country hitherto;" Jones . . . 
"has done a three months' job in one month, making the almost impossible, 
possible, despite the barrier of language. " {TIO, BuMed) 

5. A dependable, inexpensive, easily portable apparatus, for making direct 
blood pressure readings, has been developed by the Laboratory of Technical 
Development of the National Heart Institute. This device, when attached 

to a conventional electrocardiograph, produces accurate pressure record- 
ings formerly available only by the use of costly and complex instruments. 
(PHS, H. E. W. ) 

6. The National Bureau of Standards has recently completed an investi- 
gation of the attenuation of gamma radiation incident obliquely on barriers 
of lead, concrete, and concrete- equivalent material. This study, sponsored 
by the Atomic Energy Commission, was conducted by F. S. Kirn, R. J. Kennedy, 
and H. W. Wyckoff of the Bureau staff. The results indicate that consider- 
able error may be involved in some estimates of protective barrier thick- 
ness necessary to produce a specified attenuation. Estimates based on 
attenuation data for normally incident radiation were found to be several 
half-value layers low for obliquely incident radiation of the same energy. 
(NBS, Summary Technical Report 1893) 

7. It has been demonstrated that suitably prepared extracts of the spleen 
of individuals deceased from generalized carcinomatosis, will give rise to 
flocculation reactions when mixed with sera of individuals suffering from 
malignancies. The results are encouraging enough to consider the test 

a satisfactory preliminary step in the establishment of a "diagnostic cancer 
test." (J. Nat. Cancer Inst., Dec, 1954; W. F. Eisenstaedt. M. D. ) 

8. A new medium has been developed for culturing tubercle bacilli. The 
essential ingredients used are inorganic salts, glycerine, asparagine, and 
activated charcoal. The advantages of the charcoal agar medium include 



Medical News Letter, Vol. 25, No. 1 



31 



economy, reproducibility, ready availability, ease of preparation, and 
stability to sterilization in the autoclave. (Am. Rev. Tuberc.Dec., 1954; 
J. G. Hirsch) 

9. Nitrofurantoin was highly effective in the treatment of chronic urinary 
tract infection following prostatectomy. Treatment resulted in an abrupt 
fall in the number of bacteria in the urine. The drug was most effective 
against infections with E. Coli and B. Proteus. (J. Urol.,Dec., 1954; 

J. W. Draper, R. ZuFall, L. T. Rosenberg, and V. Knight) 

10. An evaluation of urologic problems from a medicolegal point of view 
appears in J. Internat. Coll. Surgeons, Nov., 1954; L. P. Wer shub, M. D. ) 

11. Diagnosis of stomach lesions by means of the electrogastrogram is 
discussed in Canadian Services, Med. J., Dec., 1954;H. S. Morton, M. Sc. , 
M. B. 

sjc 5jc >]c jlj; sjc 

BUMED NOTICE 1500 3 December 1954 

From: Chief, Bureau of Medicine and Surgery 

To: All Continental Activities Having Dental Personnel Regularly 
As signed 

Sub j : Dental technician in-service training program; training of 
instructors for 

Ref: (a) BuMed Inst. 1510.5 

This Notice acquaints addressees with the advantages of training given at 
the various Navy instructors schools for preparation of instructors in the 
dental technician in-service program. 

$ Sjj $ 5(t 5jt $ 

BUMED NOTICE 6310 3 December 1954 



From: Chief, Bureau of Medicine and Surgery 

To: All Ships and Stations Having Medical Personnel Regularly 
Assigned 

Subj: BuMedlnst 6310.3 Ch 3 (Instructions and definitions relating to 

certain diagnostic titles, Individual Statistical Report of Patient, 
and Morbidity Report) 



32 



Medical News Letter, Vol. 25, No, 1 



Encl: (1) Subject change 

This Notice clarifies the term "Personnel admitted to sick list away from 
their duty station, " and provides a replacement page 28 and a new page 28a 
for enclosure (1) of BuMedlnst 6310.3. 



If medical department personnel are to be familiar with the many 
standards related to preventive medicine they must be familiar with 
numerous publications. A reference bibliography has been prepared to 
assist them in learning these standards and the responsibilities of the 
medical department related thereto. References applicable to broad pre- 
ventive medicine functions in all types of activities are: 



Jic i|: >|e >|; i<f ij; 




Reference Publications 



Subject 



Reference Numbers 



Health Standards - -- -- -- -- - 

Training of Food-Service Personnel 
Safety Precautions - -- -- -- -- 

Sanitary Inspections - -- -- -- - 

Quarantine - -- -- - - - _____ 

Communicable Disease Control - - 
Venereal Disease Control - - - - - 



9, 10, 18 
9, 10, 13 



9, 10, 19 

3, 5, 11 

8, 9, 10 

1, 9, 10 

2, 9 



Medical News Letter, Vol. 25, No. 1 33 
Reference Publications (Continued) 



References on Selected Subjects of Particular Interest to Preventive Medicine Personnel in the Field 







US 
SHIPS 


MSTS 
SHIPS 


NAVAL 
STATION 


MARINE CORPS 
STATION 




General Mess 


51, 52 


51,52,53 


43,49,51 


14,43,49,51 


FOOD 
SERVICE 


Open and Closed 
Messes and Clubs 


1 




4, 7, 43 


14, 43 




Exchanges 


16, 17 


16, 17 


16, 17 


14 




Civilian Cafeteria 






20 


20 


WATER AND 
SEWAGE 


Water Supply and 
Sewage Disposal 


27, 28, 31 


37, 39, 46 


REFUSE 


Garbage and 
Rubbish Disposal 


24, 52 


24 


32, 50, 51 


32 


Disposal of Garbage 
by donation or sale 


50,51,52 


50,53 


50,51 


14 


SHELTER 


Housing Assignment 
and Management 






43 


14, 43 


Transient (Hotel) 

Housing 

° 








14 


Brigs 


6, 48 


6, 44, 48 


Protective Shelters 




47 


VECTOR 
CONTROL 


Pest Control 


24 


10, 33 


33 


Laboratory Animals 


9 


9 


Dog Pound, Pets, 
Wild Animals 


2 




LAUNDRIES, 
BARBER 
SHOPS, AND 
BEAUTY 
SHOPS 


When not operated 
by exchanges 


23 


23, 53 


24,33,43 


14,34,43 


24 


24, 53 






SWIMMING 


Pool water treatment; 
over- the- side 


24 


38 


14, 38 


Construction and repair of all 
Permanent Facilities 


21, 22, 23, 25 
26, 29, 30 


36, 38, 40, 41 
42, 45, 48 



sQc sfc *{c s{c ijc sjc 



34 



Medical News Letter, Vol. 25, No. 1 



Reference Bibliography 

1. U. S. Navy Regulations 

2. General Order No. 20 

3. SECNAV INSTRUCTION 4063. 1 

4. BUPERS Manual - C-9501 and C-9505 - Messes 

5. NAVPERS 91921 - Instruction In Sanitary Precautions for Food- 

Service Personnel 

6. NAVPERS 15825 - Brig Manual 

7. NAVPERS 15847 - Manual for Commissioned Officers' Messes 

Ashore 

8. OPNAV 34P1- U.S. Navy Safety Precautions 

9. Manual of the Medical Department 

10. NAVMEDP-126 - Manual of Naval Hygiene and Sanitation (NAVMED 

P-5010 will supersede when published) 

11. NAVMED P-1333 - Instructor's Guide, Sanitary Food Service 

12. NAVMED P-5026 - Medical Compend 

13. NAVMED P-1288 (Forthcoming Revision NAVMED P-5036) - 

Interviewer's Aid for V. D. Contact Investigation 

14. Marine Corps Manual 

15. Landing Party Manual, U.S. Navy 

16. Navy Exchange Manual, Operation of Functions of Navy Exchanges 

17. Navy Exchange Regulations 

18. The Control of Communicable Diseases In Man (APHA) 

19. NCPI 88 - Industrial Health Program 

20. NCPI 65.4 - Food Services 

21. BUSHIPS Manual - Chapter 33 - Life Preservers, Living and 

Berthing Equipment 

22. BUSHIPS Manual - Chapter 34 - Commissary Equipment 

23. BUSHIPS Manual - Chapter 35 - Laundry 

24. BUSHIPS Manual - Chapter 36 - Sanitation 

25. BUSHIPS Manual - Chapter 37 - Medical and Dental Appliances 

26. BUSHIPS Manual - Chapter 38 - Ventilation and Heating 

27. BUSHIPS Manual - Chapter 48 - Piping 

28. BUSHIPS Manual - Chapter 58 - Distilling Plants, Sections I and II 

29. BUSHIPS Manual - Chapter 59 - Refrigerating Plants 

30. BUSHIPS Manual - Chapter 64 - Lighting 

31. BUSHIPS Manual - Chapter 82 - Boats and Life Floats 

32. NAVDOCKS TP-Pu- 1 - Refuse Disposal 

33. NAVDOCKS TP-Pu- 2 - Pest Control 

34. NAVDOCKS TP-Pu- 3 - Power Plant Water Conditioning, Chapter 4 

- Internal Combustion Engines, Chapter 5 

35. NAVDOCKS TP-Pw- 1 - Storm Drainage Systems 

36. NAVDOCKS TP-Pw- 9 - Industrial Facilities 

37. NAVDOCKS TP-Pw- 12 - Water Supply Systems 



Medical News Letter, Vol. 25, No. 1 



35 



Reference Bibliography 



38. NAVDOCKS TP-Pw-13 - Special Services Facilities 

39. NAVDOCKS TP-Pw-15 - Sewerage Systems 

40. NAVDOCKS TP-Pw-16 - Storage Facilities 

41. NAVDOCKS TP-Pw-17 - Training Facilities 

42. NAVDOCKS TP-Pw-22 - Medical and Dental Facilities 

43. NAVDOCKS TP-Pw-23 - Housing and Subsistence Facilities 

44. NAVDOCKS TP-Pw-24 - Administration and Security Facilities 

45. NAVDOCKS TP-Pw-30 - Maintenance and Operation of Public 

Works and Public Utilities 

46. NAVDOCKS TP -PL- 6 - Water Supply for Advanced Bases 

47. NAVDOCKS TP-PL-8 - Personnel Protective Shelters 

48. NAVDOCKS TP-TE-4 - Basic Mechanical Engineering 

49. BUDOCKS Design Criteria No. 3 - Refrigeration 

50. BUSANDA Manual - Vol. II 

51. BUSANDA Manual - Vol. IV 

52. BUSANDA Manual - Vol. VIII 

53. NAVSANDA No. 236, MSTS Supply Instruction 

ajc !fc 9|C SQC 3|C 

Industrial Medicine 



Ac ou s ti c Trauma: A Clinical and Laboratory Study 

Acoustic trauma is a man-made problem. Nature has no sound 
sources that damage the ear. But industrial and military conditions 
expose the human ear to sound intensities for which it is not made, 
for which it is not prepared, and against which it is not protected. 

More members of the armed forces are being exposed to ex- 
plosions and gunfire and to loud sustained noises by airplane motors, 
jet engines, diesel engines and other noise -producing equipment. In 
industry, potential dangers to hearing arise from sustained excessive 
noises of machinery. The noises of the "jet age" pose a problem 
that is not yet clearly understood. Immediate laboratory and 
clinical observation are needed. 

Through the use of a high speed motion picture camera, record- 
ings have been made of the ears of experimental animals exposed to 
detonations. Rupture of the eardrum and fracture of the tiny bones 
inside were observed. 

The ear possesses a series of protective devices against ex- 
cessive sound. The most important protection is the acoustic reflex 



36 



Medical News Letter, Vol. 25, No. 1 



of the middle ear muscles, which contract on acoustic stimulation. 
No effective treatment is possible once acoustic trauma has taken 
place and the nerve structures of the inner ear have been 
destroyed. It is therefore all-important to prevent acoustic trauma 
in the cochlea. A practical solution for industry is well within the 
realm of possibilities. Construction of less noisy machinery will 
help overcome this serious industrial hazard. (J. Internat. Coll. 
Surgeons, August 1954; H. G. Kobrak, M. D. , Ph. D. , Chicago, 111.) 

*4# jfa> sJfe sle *b 
r F " I" - 1 - "i - 

The Significance of Nonoccupational Disability in Industry 

Work disabilities resulting from nonoccupational causes are 
a very important factor, in both decreasing the amount and in- 
creasing the cost of industrial production. 

Absenteeism is divided into two types, namely, voluntary 
absences and involuntary absences. The former are due to reasons 
other than illness, while the latter are caused by personal ill- 
health. Voluntary work absences are reasonably constant in 
volume within any given employee body. In contrast, involuntary 
absences, almost always unexpected and unplanned, have durations 
which are usually indeterminate, at least at the onset. 

Disabilities resulting in absence from work are usually con- 
sidered under three principal classifications: 

(1) Occupational injury. 

(Z) Occupational sickness. 

(3) Nonoccupational sickness or injury. 

Category number (3), nonoccupational sickness or injury, is 
responsible for the major proportion of work absences of all types. 
Gafafer (U. S. Public Health Service), in studies on a number of 
varied reporting organizations, reports on the annual number of 
absences per 1,000 persons due to nonoccupational sickness and 
injury that are disabling for 8 consecutive calendar days or longer. 
For the 10-year period from 1941 through 1950, he reports an 
average incidence of 117. 7 for males and 229. 3 for females, the 
female rate being 195% of the male rate. 

The total cost to industry of nonoccupational absenteeism may 
amount to as much as 1. 8% of the total payroll of the industry. 

Other over-all estimates place the total time lost each year 
by the Nation's industrial work force as the equivalent of 2 million 
men working full time for the entire year. (George F. Wilkins, M. D. , 
Harvard Symposium on Industrial Health, 4 April 1953). 
(NOTE --Continued efforts are necessary to reduce civilian employee 



Medical News Letter, Vol. 25, No. 1 



nonoccupational disabilities on naval stations. The magnitude of 
the problem indicates that the medical officer in charge of an 
industrial health program should work closely with management 
and the Office of Industrial Relations, especially the safety de- 
partment, in a combined endeavor to lower the incidence of 
disabilities of this type. ) 

sjc sjc sjc sQc J^C 3§C 

E nvironmental Medicine in Industry 

The following quotations were taken from a paper given by 
C. Richard Walmer, M. D. on 8 December 1953 at the Mellon 
Institute, Pittsburgh, Pennsylvania. The paper presents an ex- 
cellent general summary of environmental medicine in industry 
and is highly recommended for reading because of its applica- 
bility to naval industrial medicine: 

"An effective environmental health program in industry is, 
of course, beneficial to the employee, the employer, and the 
community. To the employee, poor health means loss of wages, 
a reduced period of useful and productive capacity, and the need 
for making arrangements to provide for himself and his de- 
pendents when income fails. Ill, injured or improperly placed 
employees mean loss of service, decreased efficiency, low 
morale, and increased manufacturing cost to the employer. To 
the community, all of these factors mean decreased prosperity, 
increased welfare costs, and, perhaps, labor strife. 

"The success of the medical program will depend largely 
upon the manner in which it is organized and administered. The 
industrial physician needs to be more than a good clinician. As 
a matter of feet, he must have qualifications and training which 
most good clinicians do not have. For example, he must be an 
extremely able administrator, and he must have the ability to 
fit into an organization and work with people. The industrial 
physician must have an understanding of production problems, 
the principles of management, and the essentials of personnel 
work. His clinical knowledge must include a great deal which 
the average physician in private practice does not ordinarily 
need to know, such as toxicology and the recognition of hazards 
in industrial environment. The physician concerned with en- 
vironmental medicine in industry cannot make a proper preplace- 
ment examination unless he is familiar with the job, its physical 
demands, and its inherent hazards, as well as the physical 
capacities and limitations of the employee. 



38 



Medical News Letter, Vol. 25, No. 1 



"Appropriate physical surroundings in the medical department, capable 
medical personnel, and efficient medical service foster the employee's and 
the job applicant's confidence in the company, thereby promoting the growth of 
a successful industrial relations program. In fact, the applicant for a job 
forms much of his first impression of the company during his pre-employment 
examination, and the sick or injured employee is particularly impressionable 
during his visits to the medical facility. The attitude of both toward the 
company can be influenced tremendously by the way the medical department 
receives them. " 

*fr jjg jjg jjg jjjj 

Insect and Rodent Control 

Precautions in the Use of Insecticides 

The measures used in the control of insects and other arthropods re- 
quire special precautions. Chapter 10 of the Manual of Naval Preventive 
Medicine, "Insecticides and Dispersal Methods," (NavMed P-5010-10) and 
"Pest Control" (NavDocks TP -Pu-2) should be used as supplementary ref- 
erences to the following discussion. 

Basic Precautions. - -Materials which are insecticidally effective are, 
with few exceptions, potentially toxic to humans; in certain instances, these 
materials are also either inflammable or explosive. This holds equally true 
for most of the solvents used in the preparation of insecticides. Paragraphs 
14301 to 14313 of the U. S. Navy Safety Precautions Manual present the 
safety precautions necessary to the handling of solvents. All personnel who 
routinely mix, store, or apply insecticides should have full knowledge of the 
characteristics of the material being used (see NavMed P-5010-10, para- 
graphs 10-41 to 10-46). Such personnel should be fully aware of the danger 
the material offers to man and other animals and of the effect it may have on 
plants, finished surfaces, fabrics, and other materials. Further, they 
should have a knowledge of the adequate but safe application rates for the 
usual formulations employed. Normally, no serious effects will result to 
workers, or to human or animal populations exposed to the treated environ- 
ments, if necessary precautions are followed and if formulations are accurately 
prepared and applied. Specific precautions to be observed in the use of in- 
secticides are as follows: 

1. Personnel. 

Consult a physician immediately in the event of internal poisoning 
or of serious skin contamination. This should also be done in the event 
that nausea, vomiting, loss of weight, or loss of appetite should develop in 
personnel routinely using insecticides. 

Bathe immediately if concentrated insecticides are spilled on the skin 
and/or clothing. Personnel routinely handling insecticides should bathe and 
change clothing at the end of each workday. 



Medical News Letter, Vol. 25, No, 1 



39 



2. Use. 

Read all labels carefully and comply fully with directions given 

thereon. 

Wear special protective clothing such as coveralls and gloves when 
handling insecticide concentrates. During the field handling of insecticidal 
dusts, use a filter-type respirator approved by the Bureau of Mines; for in- 
secticidal sprays containing solvents, use a charcoal-type respirator 
approved by the Bureau of Mines. Respirators do not provide adequate pro- 
tection against high concentrations of dust and vapors encountered during 
formulation or mixing, or when applied over a prolonged period of time in 
confined spaces. Under such conditions, more positive protection is re- 
quired; this can be accomplished through the use of an approved full face- 
piece air-line respirator, or with any of the approved self-contained 
breathing apparatus. 

Do not use insecticides in the presence of open flames or very 
high temperatures. Discard solvent- soaked waste material in covered 
safety cans. Observe recommended fire prevention practices at all times. 

Protect food, drinking water, and eating utensils from contam- 
ination. 

3. Storage. 

Store all pesticides in a safe and orderly manner. Containers 
should be plainly labeled. Items bearing a "poison" label should be kept 
locked up. Do not store in the vicinity of food. 

Use special precautions when transporting insecticides to insure 
that they do not become available to unauthorized personnel. 

Protective Devices and Clothing. --The following protective items are 
listed in the Catalog of Navy Material: 

1. Respirator, filter -pad half-mask (mechanical), Type C. Stock 
No. G37-M-315. Class 1 filter pads, color red, for Type C half-mask. 
Stock No. G37-R-97. 

2. Respirator, twin -cartridge (chemical), half-mask, Type B-2. 
Stock No. G37-M-314. Filter cartridge activated charcoal refills for Type 
B-2. Stock No. G37-R-96. 

3. Respirator, air-line mask, full facepiece. Stock No. 
G37-M-57-50. Filter cartridge activated charcoal refills. Stock No. 
G37-R-96. 

4. Air -line mask, full facepiece, modified to use two cylinders of 
compressed air. Stock No. G37-M-57. 

5. Self- generated oxygen breathing apparatus. Stock No. 
GF-23-B-289-60. 

6. Solvent-resistant rubber gloves. Stock No. G37-G-2593 (sizes 

9-H). 

7. Coveralls. Stock No. G37-C-2572 (medium and large) . 



40 



Medical News Letter, Vol. 25, No. 1 



P r ot e cti ve R e gul ation s . - - R e gulato r y naval instructions pertaining 
to the use of insecticides: 

1. BUMEDINST 6250. 3 of 23 April 1953. This instruction lists 
the precautions required of naval personnel in the use of standard in- 
secticidal items. 

2. BUSHIPS ltr 49-275 of 5 April 1949- This letter cautions 
commands on the shipboard stowage of xylene-based DDT emulsion, an 
extremely inflammable material. Stock numbers are given for safe DDT 
emulsion concentrates for shipboard stowage. 

3. SECNAVINST 6250. 2 of 31 March 1953. This instruction is 
designed to prevent unnecessary procurement of nonstandard pesticides 
and pesticide dispersal devices, and to insure maximum safety and 
efficiency in those isolated instances where nonstandard items are re- 
quired. (Kenneth L. Knight, Cdr. (MSC) USN, Preventive Medicine 
Division, Bureau of Medicine and Surgery) 

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